Joint Commission Basics
During the JC survey, the surveyors will talk primarily to: A. The Hospital Administrators B. The doctors, nurses and staff C. The patients D. The Houston Chronicle
B. YOU! That's why you are playing this game, right?
Name one of the 2014 National Patient Safety Goals
NPSG 1- Improve accuracy of patient identification NPSG 2- Improve effectiveness of communication among caregivers NPSG 3- Improve safety of using medications NPSG 6- Improve the safety of Clinical Alarms NPSG 7- Reduce risk of health-care associated infections NPSG 9- Reduce the risk of falls NPSG 14- Prevent health care-associated pressure Ulcers NPSG 15- The organization identifies safety risk inherent to the patient population Universal Protocol
The corridors and hallways need to be clear of cludder. Nothing is to be left in the hallways for more than____
30 Minutes
What is the procedure for medication administration?
Scan patient armband at the bedside, identify patient by name and account # on armband, scan each medication, open meds in front of patient. label syringes prepared in the med room.
When must the Admission INITIAL assessment be competed?
Within 24 hrs of admission
What is "tracer methodology"?
Surveyors analyze a hospital's systems by following individual patients through their hospitalization, evaluating multiple care units, departments, and services rendered to the patient.
Name one way you reduce the risk of health-care associated infections in your department.
Handwashing with soap and water before and after each patient contact: Even if you used gloves wash vigorously for 15 - 20 seconds. Alcohol-based hand rubs may be used if there is no visible soiling and C. Diff is not suspected. Use of artificial or long fingernails is prohibited. LATHER UP!
How do you respond in a Code Red situation?
RACE and PASS:
Rescue people in immediate danger.
Activate Alarm
Contain fire by closing all doors and windows
Extinguish/Evacuate using good judgement when deciding to fight a fire.
Pull the pin,
Aim the nozzle at the base of the fire
Squeeze the handle while crouching low
Sweep back and forth at the base of the fire
What is our policy regarding range orders?
Begin administering the medication at the lowers level. If no response within the expected onset of action time for the medication, the does may be increased within the ordered range.
Frequency will automatically be set to the shorter interval of the range.
How often is a pain assessment and reassessment completed?
Pain assessment should be documented on admission, and at least every shift. Reassessment should be documented within 90 mins of administration of PRN pain medication or non-pharmacological intervention.
What is HIPPA? Name one way protected health information is kept private in your department? Who is Northports Privacy Officer:
Health Insurance Portability and Accountability ACT. States the PHI may only be used for purposes of treatment, payment, healthcare operations. Examples of how to protect a Veterans PHI: 1. Don't discuss patient information in the hallway or elevators, 2. Keep doors to exam rooms closed, 3. close computer screens when away from PC.
Name the patient identifiers used at Infirmary Health
Patient Name and 7 digit hospital account number.
NEVER use the patient's room number as an identifier.
Who can turn off the medical gases(oxygen) in the event of a fire?
Nursing, Pulmonary Services, and Plant Ops are authorized to turn off medical gases.
What are examples of High alert medications?
Anticoagulants, concentrated electrolytes, chemotherapeutic agents, SC/IV bolus insulin injections, narcotic administered by PCA pump, thrombolytics, promethazine IV, Humulin U-500, Cytotec, hydromorphone, paralytic agents, Digoxin.
How is the Plan of care developed?
How often is the plan of care reviewed?
The pt's plan of care should be based on the specific needs of the patient identified by the H&P, assessment, procedures performed and results of diagnostic testing. It should be individualized to the patient.
Care plans should be reviewed every shift and each goal must be documented on at the end of the shift.
It is a good practice to discuss plan of care and goals with the patient and write your plan of care on the patients white board.
When is patient hand-off communication report used?
Bedside shift report, when patient is going off the unit for a procedure/test (ticket to ride), upon transfer of patient to another unit or facility.
A handoff report is given between healthcare providers to provide continuity and safe care. Report should be interactive with opportunity to ask questions and verify information.
What is the process when you have received a critical lab result from the lab?
Call the ordering physician upon notification of the critical result. Document the notification was made to the physician in the flowsheet of the record under provider notification. If no response is received from the physician within 30 minutes, notify your manager or the nursing supervisory and document the date, time, critical result and manager or supervisor notified.
What is the Kill/Wet/Dwell Contact Times (To Kill germs) using Sani-wipes?
Purple top?
Orange bleach top?
Surface must sty wet & air dry.
Purple top to remain wet for 2 minutes.
Orange top of bleach wipes for 4 minutes.
No fanning or wiping dry!
How often are is IV Tubing changed?
Primary and secondary continuous infusion sets should be changed every 96 hours. intermittent administration sets should be changed every 24 hours. TPN tubing should be changed every 24 hours.
Where are the patients spiritual needs addressed?
In the admission navigator in EPIC, under the Learning Assessment. For 24/7 pastoral coverage, call the operator. They have a call list.
What is the proper way to store clean linen?
Clean linen should be stored in closed cabinets or on covered carts. Clean linen should never be stored with dirty linen.
Name 3 of the unapproved abbreviations.
(1) .U or u (unit) (2) IU (international unit) (3) Q.D., QD, q.d. (daily) or Q.O.D., QOD, q.o.d. (every other day) (4) 1.0 (no terminal zeros) .5 (always use a leading zero - "always lead never follow" (5) MS, MSO4,MgSO4 (morphine sulfate or magnesium sulfate)
When does an order have to be received to initiate Non-violent, non-self-destructive restraints?
A physician order should be obtained prior to applying restraints. Re-evaluate patient at least every 2 hours for continued use of restraint. Obtain a new physician order each calendar day if patient continues to need restraints.
What are our safety stops when administering high risk medications?
TALLman lettering, independent double checks, second nurse verify, automated alerts, color differentiation, separation in Omnicell.
What do you do if your patient needs a language interpreter?
Dial "0" for the hospital operator and request the language line or contact the house supervisor. Patients have the right to a trained interpreter to ensure they fully understand information provided in order to give informed consent. Family members or friends should not be used as interpreters when communication regarding the patient's treatment and consent is needed.